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Abstract

Retrenchment of government services has occurred across a wide range of sectors and
regions. Care services, in particular, have been clawed away in the wake of fiscal
policies of cost containment and neoliberal policies centred on individual responsibility
and market autonomy. Such policies have included the deinstitutionalisation of care
from hospitals and clinics, and early discharge from hospital, both of which are predicated
on the notion that care can be provided informally within families and communities.
In this paper we examine the post-birth "care crisis" that new mothers face in one
region of Canada.

Method

The data are drawn from a larger study of social determinants of pregnant and new
mothers' health in Victoria, Canada. Mixed methods interviews were conducted among
a purposive sample of women at three points in time. This paper reports data on sample
characteristics, length of stay in hospital and health service gaps. This data is
contextualised via a more in-depth analysis of qualitative responses from Wave 2 (4-6
weeks postpartum).

Results

Out results show a significant portion of participants desired services that were
not publically available to them during the post-birth period. Among those who reported
a gap in care, the two most common barriers were: cost and unavailability of home
care supports. Participants' open-ended responses revealed many positive features
of the public health care system but also gaps in services, and economic barriers
to receiving the care they wanted. The implications of these findings are discussed
in relation to recent neoliberal reforms.

Discussion & conclusions

While Canada may be praised for its public provision of maternity care, mothers' reports
of gaps in care during the early postpartum period and increasing use of private doulas
is a worrying trend. To the extent that individual mothers or families rely on the
market for care provision, issues of equity and quality of care are pivotal. This
paper concludes with suggestions for further research on the impact of recent changes
in post-birth care on new fathers and on inequities in pre and post-birth care in
less-resourced regions of the world.

Keywords:

Background

Fiscal policies of cost containment in recent decades, coupled with neoliberalisation
policies stressing individual responsibility and reliance on market forces, have resulted
in the contraction of state provided care services in a range of countries [1]. Termed ‘de-familialising’, these establish mechanisms for the provision of care
through publicly-funded social services, including housing, primary and extended health
care and childcare, which are typically seen in democratic welfare states [2,3]. Reliance on market mechanisms commodifies care arrangements, transforming care into
‘products’ for purchase, and the means of care provision into specialized jobs and
occupations [4]. These responses reflect the ‘care deficit’ - the situation in which the demand for
care exceeds its supply [5]. The shift from publicly-funded hospital maternity care to privately-based home-based
post-birth care is one example of this trend.

Research in a number of countries shows an increasing trend for maternal services
to focus on infant health, and on the surveillance of parents and their parenting
skills, rather than on the provision of broad ranging support to new mothers during
early parenthood [6,7]. A wide range of reports over the past several years produced in the United Kingdom,
for example, has centred on the notion of “early years” or “foundation years” interventions,
with the aim to reduce child poverty and inequality in life chances, and to ultimately
forestall persistent social problems linked to early parental neglect [8-11]. Within these reports, the importance of mothers’ mental and physical health is cited
in relation to childhood health and well-being, but short-lived, rather superficial
interventions such as brief visits by “health visitors”, often aimed at screening
for risks, are proposed as solutions. Additionally, such visits are framed almost
exclusively in terms of expected improvements in mother-child bonding (‘attachment’)
and/or breastfeeding rates, and their purported consequences for early brain development
and immunity, rather than any substantive improvements in the health and overall well-being
of mothers themselves [11-15]. Ironically, while “parental warmth and attachment” is listed as a requirement for
healthy childhood development and for forestalling social inequalities in health and
overall life chances, social welfare retrenchments have reduced families’ – and specifically
new mothers’ - abilities to provide such care [16].

These developments have been accompanied by major changes in the delivery of maternity
services. One change is the steady increase in Cesarean-section (CS) rates. In the
United Kingdom, CS rates increased from 12% in 1990–1991 reaching 23% in 2005/2006.
CS rates are even higher in The United States, at 30% in 2005 [17] and Australia, where 31.5% of women gave birth by CS in 2009 [18,19]. As noted below, Canadian CS rates are also high. In contrast, Finland has seen no
increase in its CS rates of 16–17% since 1994; indeed, the Finnish rate has declined
slightly since 2005/2006. The World Health Organization (WHO) recommends rates of
10%-15% [20]. High CS rates suggest elective intervention, and while they are an important birth
option, they are also linked to increased risks for maternal and infant morbidity,
and therefore should not be practiced in excess of evidence based guidelines [21].

Another change in the delivery of maternity services is decreasing lengths of hospital
stay post-birth. In the past two decades there has been a shift as cultural norms
about the need for a ‘lying in’ period have eroded [22]. From a standard hospital lying-in period of between 1-2 weeks for uncomplicated
vaginal birth in the 1950s, to recent length of post-birth in Canada, United Kingdom,
United States (US), Sweden and Australia is now around two to three days or less [23]. Indeed, in the US by the early 1990s, the lying-in period had taken on a “drive-
through” character as hospital stays of 12 to 24 hours for uncomplicated vaginal births,
and 48 to 72 hours for uncomplicated CS births have become standard [24]. As with rising CS rates, there has been considerable controversy surrounding the
question of whether earlier discharge of mothers and babies is safe and linked to
positive health outcomes [25].

To date, the implications of these trends in the direction of the privatisation and
commodification of post-birth care have not been evaluated from the point of view
of the main recipients of care. In this paper, we explore the hidden costs of these
developments for new mothers in one Canadian city. Below we provide a background of
recent changes in post-birth care in Canada and an overview of our methods. This is
followed by a presentation of descriptive characteristics of our research participants,
length of stay in hospital and health service gaps. We contexualise our data via a
more in-depth analysis of qualitative responses from new mothers. We then discuss
our results in light of recent trends in the privatization and marketisation of post-birth
care, and make suggestions for further research on the impact of recent changes in
post-birth care on new fathers, and on inequities in pre- and post-birth care in less-resourced
regions of the world.

Post-birth care in Canada

Costs of maternity services in Canada, including salaries for service providers, are
paid for through general taxes and included as public services under the country’s
universal health care program, Medicare. Virtually all pregnant women give birth in
hospitals and receive maternity care from obstetricians or family physicians, although
professional midwives and nurse practitioners have emerged as autonomous providers
since the mid-1990s.

Similar to many other countries, Canada has revamped its reproductive care services
in recent decades [26]. The length of time Canadian women spend in hospital following childbirth has decreased
dramatically, from five-seven days in the 1960s to between 24 to 48 hours after vaginal
delivery in the current decade [27]. As noted earlier, this trend has taken place at the same time that the CS rates
have steadily increased, with total national CS increasing from 17.6% in 1995, to
21.1% in 2000 and 25.6% in 2004. The variation in CS rates are almost double across
the provinces/territories. In British Columbia (BC), while Saskatchewan (20.8%) and
Manitoba (19.8%) had among the lowest rate. BC has the second highest rate in Canada
at 30% [28]. In BC (2005), Vancouver Island Health Authority (where our study took place – see
below) had the highest CS rate of 32% and the Northern Health Authority had the lowest
rate of 26% [29]. Furthermore, while the CS rate for mothers age 40 or older is currently double (42%)
the rate for mothers age 20 to 24 (21%), there is little evidence that this variation
is based on mothers’ demand -- the so called “too posh to push” argument [30]. Changes in obstetric practice and neoliberal reorganization of health care environments
are among the main reasons for increased CS rates among Canadian mothers across all
age groups [31].

In addition to women being discharged earlier to private home environments, Canada’s
public health care system currently covers a narrow range of post-birth care services.
Typically, where post-birth care services exist, they are comprised of surveillance
and referral, rather than more substantive and intensive home-based services [32]. Post-birth care services vary substantially by region, and federal involvement is
limited to the provision of informational supports for the provinces and the publication
of national guidelines for maternity and newborn care [33]. Publicly-funded post-birth care following discharge from a hospital involve a single
home visit from a public health nurse; indeed, in some regions this service has been
reduced to a single telephone call.

On the positive side, publicly funded midwifery services have become available for
care throughout pregnancy, birth and post-birth. After considerable public debate
and advocacy by consumer organizations, in the mid-1990s midwifery became institutionalized
and publicly-funded initially in the province of Ontario, with BC following soon thereafter.
Today, the midwifery option is available in seven regions in roughly half of the provinces
in Canada [34]. Midwives hold a university bachelor’s degree through one of the newly-established
direct-entry (non-nursing prerequisite) programs and are certified by the provincial/territorial
Colleges of Midwives to work as a primary care provider during pregnancy, labour and
delivery, and the immediate post-partum period. Midwifery care is thus a viable option
for pregnant women in many regions and their midwifery services, including post-birth
care services, are reimbursed through the public purse.

Yet the impact of this midwifery expansion to date has been small. In fact, less than
5% of births in Canada are currently attended by a certified midwife [35]. While the percentage is higher in some provinces, including British Columbia (11%
midwifery attended deliveries in 2011) where our study was conducted [36], a substantial proportion of women in all parts of the country who want to see a
midwife are currently unable to find one. Many pregnant women and their families must
pay for their care out of pocket for both pre- and post-birth care from privately-practicing
midwives. Further complicating access to midwifery services is the fact that, even
where such services are publicly funded, less-educated women, younger mothers, women
without a partner, indigenous women, and women living in rural and remote areas or
socioeconomically disadvantaged communities, are less likely to have access to midwifery
care during pregnancy, labour and delivery and in the post-birth period [37].

As publicly-funded and delivered post-birth care services have contracted, a wide
range of services for purchase on the market has grown to fill the burgeoning care
gap. While these services have garnered media attention in Canada [38], there currently exist no published research studies on the for-profit postnatal
services that have emerged to fill in the post-birth care gap. Post-birth doulas advertise
and deliver a vast array of high-intensity, practical services and supports, including
newborn care, breast- and bottle-feeding support, child-minding services, meal preparation,
household chores and management (including laundry, plant, and pet care services),
errand-running, and peer support/counselling. These providers advertise a similarly
wide range of degrees in areas such as nursing and midwifery, and/or have completed
specialized training as post-birth doulas and lactation consultants. Unlike the interventions
offered though state-directed programs, commodified forms of post-birth care appear
to be carefully and flexibly tailored to the unique needs of each woman, and can be
contracted out for extended periods of time (i.e., an overnight stay, or an entire
week). As Carroll and Reiger (2005: 101) state: these postmodern consultants fill
“a specific role not only within maternity care institutions, but in private practice
in the community” [39].

But such privately-delivered post-natal care tends to be quite expensive, making such
support accessible only to those who are able to pay for it. Providers who advertise
online generally charge around $25(CAD) on a per-hour basis, or anywhere from $100
to $1000(CAD) for overnight or week-long package deals, respectively. No information
currently exists on user demographics, patterns of use, or outcomes associated with
these forms of commodified care, though such information would offer insight into
the types and levels of unmet needs that exist.

In sum, the provision of post-birth care in Canada is stratified by geographical location,
social status factors, and capacity to pay for services on the market [26,39,40]. Rising CS rates, early discharge from hospital and limited state-provided post-care
support, especially in jurisdictions without public provision of midwifery, leave
new mothers and their families with two main alternatives: to rely on their own resources
for care provision, or to rely on the market for the purchase of care services. Next
we explore these challenges for new mothers in one Canadian city.

Methods

Study design and data collection strategies

The data analyzed in this paper are drawn from a larger study of social determinants
of pregnant and new mothers’ health in one urban region of BC, Canada. A key objective
of the project was to comparatively examine the experiences of mothers under physicians’
and midwives’ care. Our sample selection was theoretically-informed and based on two
overarching criteria: (i) diversity of backgrounds, and (ii) choice of maternity care
provider. Our purposive sample included pregnant women who represented a range of
ages, ethnicities, educational levels, parity and economic status and had chosen either
a certified midwife or physician for their primary attendant. The proportion of women
choosing to have the care of a midwife is thus artificially high compared to the general
population, which estimates put at 25% in the local region, a utilization rate higher
than that of any other city in Canada [41]. We attained our sample by distributing posters and flyers to places that pregnant
women frequent in the Victoria Census Metropolitan Area (CMA), including physicians’
and midwives’ offices, pre-natal classes, single-parent resource centres and low-income
outreach programs. While our non-random sampling technique precludes us from knowing
if our findings can be generalized to the broader regional population, we believe
that our sample reflects the diversity of social and economic backgrounds and the
style of maternity care available through the public health care system in the area
(see Table 1).

Table 1.Selected characteristics, study population compared to the Victoria Census Metropolitan
Area (CMA), 2006. Income is in Canadian dollars (CAD)

One-hundred and six women responded to our research postings, with an estimated population-based
recruitment rate of 3.5%. We completed interviews with 93 women any time during their
third trimester of pregnancy (wave 1), 89 at 4 – 6 weeks post-birth (wave 2), and
83 during the 4 – 6 months post-birth period (wave 3). Thirteen participants were
lost at each stage because they became unavailable for an interview or had scheduling
conflicts, had a therapeutic abortion or still birth, or moved outside the region
and were not accessible by telephone. Our final participant retention rate for wave
3 was 89 percent (n=83). Our analysis of the 13 participants who were not included
in the study due to attrition or missing/incomplete data shows that they had a lower
mean income and education level than the others.

Just under half (n=42) of wave 1 participants were under the care of a certified midwife
and just over half received care from either a maternity physician or obstetrician
(n=51). The four interviewers involved in data collection collaborated during pre-testing
of the instruments and interviewer training to ensure consistency of delivery. The
majority of interviews were conducted in participants’ homes; others occurred at places
of convenience to participants, such as research offices and coffee shops. Whenever
possible, the same interviewer conducted all three of a participant’s interviews to
facilitate rapport. We were interested in hearing the women’s own voices about their
pregnancies, birth experiences and post-birth care options and gaps, and so the interviews
included both closed and open-ended questions. In addition to collecting standard
demographic information, questions focused on a variety of health related topics such
as health service utilization, indicators of physical and mental health, and experiences
of pregnancy and early motherhood including sources of stress and social support.
To facilitate triangulation of data on topics of central interest within the study
(birth, parenting, care, and health experiences), the interviews included both closed
and open-ended questions.

A feature of our mixed-methods design was to follow many of our closed-ended questions
with a probe asking participants to explain their response, and then asking them an
open-ended follow-up question. The two questions relevant to our analysis are: How satisfied were you with the post-birth care you received from paid care providers
from the time of your baby's birth, up to the present? Would you have wanted any of
these types of care, but they were not accessible to you? If so, what were the barriers
to your accessing this care? We believe this design that mixes quantitative and qualitative data collection methods
is richer than exploring this subject with only one method. This is because it enables
us to quantify and qualify key variables, giving us an opportunity to triangulate
both types of data on topics of interest and to elaborate on the meaning and experiences
subsumed within survey statistics. Comparing data from the different methods also
helps to determine the validity of measures, providing insight for design innovations
in follow-up studies. In addition, after having completed key survey questions, participants
were keen to elaborate on what factors they had considered when choosing their survey
answer and to narrate stories that exemplified their experience. Thus, we believe
this instrument design is more respondent-receptive in practice. We delivered potentially
sensitive closed- and open-ended questions, including those on income and depression,
using a self-administered, written questionnaire completed by the participant at the
end of the face-to-face interview. All questions were read aloud by the interviewer,
with the exception of self-administered items and the interviews were tape-recorded.
At the completion of the self-administered portion of the interview, participants
placed their answers in an envelope, sealed the contents and returned the data to
the interviewer. This process allowed for extra assurance of confidentiality and anonymity
of the participants, as the self-administered portion was reviewed at a later date.
Responses to closed-ended questions were entered and analyzed using SPSS 12.0 software.

In the case of this paper, the qualitative data were analyzed using the following
procedures. The second author initially coded the relevant transcribed transcriptions,
and the third author repeated this exercise and independently identified the central
themes in the answers for each question. Based on an analysis of the lists they arrived
at independently, the two authors drew a third list of common themes by question.
The first author then reviewed the list of themes and a final version was made. The
transcriptions were subsequently coded thematically by the second author and a few
transcriptions were coded by two of the first and third authors. These transcriptions
were compared for coding consistency/reliability. Our study was approved by the Human
Research Ethics Board at the University of Victoria, Canada.

Results

Sample characteristics of participants

Our descriptive characteristics are based on the subsample of wave 2 participants
(n=89) (interviewed 4-6 weeks post birth) who gave complete answers on questions regarding
their access to support and care in the post-birth care period. As shown in Table
1, participants were slightly more likely to identify being of Aboriginal or visible
minority background, and to have lower income and lower home ownership than the population
in the study region [42]. Participants had somewhat higher levels of high school completion compared to the
local population. The lower income and home ownership of the sample is likely a reflection
of their younger, childbearing age.

Participants’ median number of days in hospital was 2.4 days overall, and 1.9 days
for persons reporting a vaginal birth; these findings support the literature noted
earlier regarding a reduction in length of hospital stays following the birth of a
child compared to earlier generations. While the demedicalisation of birth, as evidenced
by short term hospital stays, may not in and of itself signal a lack of care in the
post-birth period, coupled with the finding that approximately one third of participants
(33.8%) reported that they desired post-birth care services that were not available,
it is not clear that reductions in hospital stays have been accompanied by increases
in community-based care options. The closed-ended data also show that greater proportion
of participants with incomes below the median for the census region reported they
would have liked post-birth care that was unavailable to them (39.5%) compared to
participants with an income above the median (27.3%). The most commonly cited barriers
to obtaining post birth support services included “cost” (42.8%) and “unavailability
of home care supports” (38%).

As noted above, we asked participants to expand on the topic of access to post-birth
care services, and barriers to receiving the care they wanted. The next section of
the paper focuses on themes that emerged, both in terms of participants’ satisfaction
with access to post-birth care, as well as lack of access to the services they wanted
to help them through the early stages of being a new mother.

Qualitative analysis

Satisfaction with post-birth public services

Several participants either did not identify any additional post-birth care needs,
or specifically described aspects of Canadian post-care services that contributed
to a positive experience during the first six weeks of the birth of their baby. Most
of these participants noted practitioners and services that contributed to quality
continuity of care. Sarah,a age 27 and a mom for the third time, described her satisfaction with her maternity
doctor’s team: “Just wonderful people, they’re just, they’re awesome. They really
listen; they never treat me like an overactive, over-reactive mother. You know they
always take my opinion very seriously and uh, they’re just really caring and really
great.” Another participant, Annie, expressed gratitude for the public health nurse
who visited her post-birth:

"The nurse contacted me right away when I got out of the hospital and she came to
check up on me. [I]t’s kinda nice to know that they’ll come to you. [Because], you
know, when you first get out of the hospital and especially after a C-section [you
are] sore. You don’t really wanna go anywhere; you just wanna be home. So it’s nice
to have that for them to come to you. (age 34; 1st child)"

Annie’s response addresses the importance of accessibility to health care during the
post-birth period and having services available that are flexible to the needs and
physical capacity of the new mother. Many participants mentioned positive aspects
of post-birth care also highlighted easily-accessible helpful information. This included
the 24-hour nurse hotline, which they saw as a beneficial support system for answering
questions. Participants praised the workers of the hotline service as “knowledgeable”
and “helpful” and easily accessible by phone.

Other participants discussed the benefit of having a midwife for their most recent
child. Kathy explained:

"I went with the midwife this time round [and] I just felt that I was, I felt really,
really well looked after […] it’s just so different having, you know, two women midwives
where that’s all they do, versus the GP who does all kinds of things and doesn’t specialize
in […] the amount of time, I think that’s a huge thing that they, the midwives, offer.
(age 35; 2nd child)"

Another participant, Myra, highlighted that in addition to the more lengthy visits
offered by midwives in comparison to physicians, an additional benefit was the availability
of in home postpartum care and flexible appointment times:

"I can call them [the midwives] anytime and they will come over. Like it’s not even,
it’s never a question like – if I ever needed to get in to see them now, like it was
– they came here in the first two weeks and then I’ve been going there and if I needed
to get in, I know they would just squeeze me in and - so that’s why I like it. (age
25; 2nd child)"

The dedicated time that the midwives’ spent on these participants as well as the flexibility
with regard to service time and location were greatly valued in the post-birth period.
The support and focus of midwifery care resulted in satisfactory continuity of care
and specific support for the woman based on the midwives’ expertise. The qualities
that made up a positive labour, delivery and post-birth experience were the same qualities
addressed as absent from other participants’ post-birth experiences.

Dissatisfaction with post-birth services covered under the health care system

A major theme articulated by participants’ who expressed dissatisfaction with their
interaction with the health care system was poor care during the labour and delivery
period, and a lack of follow-up during the post-birth period. Concerning her hospital
experience, Jessica stated:

"You really are like a number in the hospital. They’re, you don’t, they’re not a lot
of caring women and I’m not sure whether it’s because they’re tired of their job,
you know and they’re not happy that way or whether they’re just you know, but there
were a couple of kind women there, you know […] you just, you don’t really get that
attention that I really believe that you deserve and you need. (age 36; 3rd child)"

A second time mother, Lena, age 31, stated “I kinda (sic\ fell through the cracks a bit with this second baby… I don’t know what but nobody
called me afterwards to remind me of things like shots and so I actually went, I went
far too long before I got his shots.” Several respondents commented on a feeling that
health care providers “did not pay attention, had a “million other things to do”,
and that it would be beneficial if they could spend more time with the patient”.

Some participants identified a need for more emotional and social support services,
in particular supports that were not connected to risk assessment activities. The
desire for this type of support came from a variety of avenues, including health care
professionals, mental health services and a space to informally socialize with other
mothers. Kelsey, age 22 and a first time mom, expressed a desire to have a health
care professional to confide in while her son was in the hospital that would not “potentially
deem me ‘unfit’ to have my baby because I’m depressed or something […] that just scared
me so I, I guess I had access to somebody to talk to but I didn’t use it because I
felt it probably caused more trouble than I would have wanted.”

Women in Canada, including in the study area, are routinely screened for postpartum
depression as part of public health care services [43]. Using the Beck Depression Inventory, we found that 15% of participants at Wave 2
and 21% of participants at Wave 3 reported moderate depression symptoms [44]. Some new mothers, such as Kelsey, who identify the need for mental health services
during the post-birth period do not access the desired services because they are concerned
that doing so will undermine the perception of competency and capacity to care for
a child.

What women wanted and was not publicly available

As noted the above, thirty-four % of women wanted additional services than were provided
via the health care system but were not available due to varying factors. Many of
these women lacked a strong informal support system and the income to purchase post-care
services out-of-pocket. Theresa, a first-time mother of twins, remarked:

"Well since I’ve been home like there have been times when having the two has just
been really, really intense and really hard. I’m getting a grip on it now, but there
were times within that first six weeks that I just felt like I was gonna lose my mind.
It would be really nice if there was somehow just a number you could call, in the
community, just to, I don’t know, like listen to you for a minute or, or, I don’t
know, rush over and hold one of your babies! (age 30; 1st child)"

Sabina wished that the public health nurse would provide more continuous care during
the initial weeks after the birth. But this is not a covered public care service in
the study region, and as a result she had to go without:

"I would have liked the public nurse to come back again because she said she was going
to and she didn’t because I had breastfeeding questions and you know he had that acne,
that um, from breastfeeding and I didn’t, I didn’t, wasn’t sure whether that what
it was or not. Just questions that you have. (age 30; 1st child) "

Three-quarters (74.7%) of the new mothers in our study reported that someone, primarily
friends and family members, came forward to help them during the post-birth period;
mothers appearing to be the most common source of informal. Without such care, they
would have had to purchase it on the market, as Becky, age 33 and entering motherhood
a second time, stated: “If, if I didn’t have my, my sister and mum, I definitely probably
would consider a doula.” Other participants who wanted more post-birth care sought
out a private doula, a service which is not publicly funded. Tina was able to pay
for her doula, but saw it as an expense that she should not have to pay for:

"It would have been nice if the, you know, the doula. Like, we paid quite a bit for
the doula. [Y]ou know it’s expensive uh, anyway it would be nice if there was um public
health care. I think they’re worth it, it just like, it was something that we paid
for and we knew wanted the support so but definitely it was expensive. (Age 24; 1st child)"

Other participants who did not have access to family care or the needed economic resources
to pay for a doula went without. As Barb, age 23 and a 1st time mom, noted: “I would have liked a doula but they’re very expensive.”

Breastfeeding advice has become more commonplace in Canadian hospitals and all midwives
are trained to routinely give such advice. At wave 2, 64.8% of new mothers were breastfeeding
exclusively, but that drops to 50% at Wave 3. Eighty-nine per cent of the women reported
problems with breastfeeding their infants at 3-6 weeks postpartum; At wave 3, 35%
of them were still reporting breastfeeding problems. We asked the women who responded
“yes” to having breastfeeding difficulties what sorts of difficulties they had. Some
women had multiple problems at once, while others had one or two, and the level of
severity of each source of difficulty also varied among participants. The most prominent
of these were: sore nipples (the top source of difficulty), difficulty latching on,
sleepy baby, and milk undersupply. Karli expressed her concerns about breastfeeding,
stating:

"When we left the hospital I kinda worried because I still wasn’t, you know, breastfeeding
that… My milk hadn’t come in and there was things like that so um. It was fine in
the hospital cuz I had that support but once you go home you don’t have that support
any longer. (age 31; 1st child)"

Other respondents similarly commented that “breastfeeding was the hardest” and that
it would have been beneficial to have a lactation consultant who had time and expertise
to devote specifically to the task. As these participants note, lactation consultation
is a very important service as new mothers have a short window of time to establish
breastfeeding before they may turn to bottle/formula feeding because they are worried
that the baby is not being adequately nourished. The public health nurse visit may
not be sufficiently timely or intensive enough to meet this important need. In fact,
a lactation consultant is even a good addition to midwifery care in the first two
weeks as the midwives help with breastfeeding but some people, particularly first
time mothers, require more intensive support in early post-birth period. In our study
only one-quarter (25.8%) of participants mentioned they had used the services of a
lactation consultant in the post-birth care period.

Discussion

In this paper we examined the provision of post-birth care for mothers in one Canadian
city. The findings presented here indicate that the majority of participants were
happy with their post-care services, noting that they contributed to a positive experience
during the first six weeks of the birth of their baby. Most of these participants
noted practitioners and services that contributed to quality continuity of care. However,
a minority of the women in our study expressed a desire for post-birth care services
that were not available to them locally. Many of these women reported incomes below
the median for the census region. Unavailability of home care supports were at the
top of their list of barriers to access this post-birth care services they desired.

Post-birth care intersects the line between public and private spheres, and blurs
the state’s responsibility towards women in need of such services [45]. The adoption of neoliberal reform ideologies in countries such as Canada but also
in Australia has further pushed government responsibility away from post-natal women
and towards their families and informal support networks [26]. This push results in a greater burden for women without the financial or support
networks to secure appropriate post-birth care. New mothers who do not have secure
informal social supports or the means to pay for services out of pocket – one-third
of our sample - often fall through the safety net in these contexts.

The cultural politics of post-birth care are premised on the often mistaken assumption
that women need little if any care after their discharge from hospital, an understanding
which is, in turn, based on very narrow conceptions of care itself [45]. Where government-based home care is provided within these contexts, it is generally
limited in scope, fragmented in terms of its provision across multiple carers, and
differs in type and quality between hospitals and geographic regions [45-47]. To the extent that community-based services exist, they tend to focus on the infant
rather than the mother, or on a form of surveillance aimed at identifying ‘at risk’
groups. In some developed welfare states, such as Sweden and the Netherlands, the
two branches of the welfare state have cooperated and integrated to such an extent
that they are able to meet the care needs of women in the post-birth period [26,48-50]. In other countries, including the US, Australia, the UK and Canada, these branches
do not closely overlap. It is within the latter contexts that a care gap exists. In
some of these countries, midwives and family networks provide adequate social care
to some new mothers but these tend to be women who are more advantaged. The market
– through the private services of doulas, lactation consultants, etc. is variously
called upon to fill the care gap [51]. To the extent that individual mothers or families rely on the market for care provision,
issues of equity and quality of care are pivotal [50,52].

The importance of post-birth care extends beyond the immediate need of providing women
with the support after the birth of their children. Setting women up with adequate
and appropriate supports in such a way that minimizes the financial and emotional
stress can not only assist with better health outcomes for the mother, but also for
her infant during the crucial period after birth. While policy documents in other
high income countries like England stress the importance of reducing inequity during
the foundational years of a child’s life, the health and well-being of the mother
in the post-birth period is lacking in this discussion [8-11]. As seen in the participants’ lived experiences of their pregnancy and post-birth
care in BC, mothers’ and children’s welfare in the post-natal period is often closely
connected. Appropriate provincial-assisted care from government services that attend
to the needs of post-natal women in turn can aid with the creation of a stable, reduced-stress
environment for children during an important phase of their life. Currently, the potential
of the postnatal period as a period of health promotion opportunity is not being fully
realized and additional supports for new parents, including those described by respondents,
which consider both parent and infant health promotion should be considered.

Concluding remarks and future research

This study is not without important limitations. Our single case study of post-birth
care in one Canadian city does not allow us to generalize to the situation elsewhere.
The non-random nature of our sample and its limited size also prevented us from ascertaining
whether the current care deficit has an especially negative impact on new mothers
who are disadvantaged due to inadequate housing, single parenthood, younger age, Indigenous
background, racial minority status, or chronic illness. Further research with a larger
and more diverse sample is needed to fill in these gaps. It was not within the scope
of this paper to investigate the impact of recent changes in post-birth care on new
fathers [53]. This will be a crucially important next step in laying the groundwork for future
research on the gendered underpinnings of postnatal care provision [54]. Finally, this paper has focused attention on inequities in one dimension of reproductive
care services in the economically-resourced regions of the world [55]. Research in lower-income countries point to the need for immediate action on far
more entrenched inequities in pre and post-birth care [56].

Endnotes

a Pseudonyms are used to protect the identity of the participants.

Competing interests

The authors declare no competing interests concerning this paper.

Authors’ contributions

The first author planned the study, and oversaw the data collection. The first three
authors performed the analysis. All authors contributed to the drafting of the initial
manuscript, and read and approved the final version.

Acknowledgements

This research was supported by a research grant from the National Network on Environments
and Women’s Health, Canada, and postdoctoral fellowships from the Michael Smith Foundation
for Health Research and the Canadian Institutes of Health Research. A deep thank you
to the women who took part in the interviews. Thanks as well to the Centre for Addictions
Research British Columbia (CARBC) for the research assistantship, the office space,
and the supportive work environment and to Marie Marlo-Barski for helping to edit
the manuscript.